BITTER TASTE OF PULSE THERAPY - Dealing with Outbreaks

For people living with Multiple Sclerosis, flair-up and pulse therapy are often used and certainly dreaded words. But do all people with Multiple Sclerosis know what these terms mean?

There is currently no cure for MS, but effective strategies are available to control the disease and improve overall function of patients. Available treatments have two main goals: alleviate acute symptoms and prevent outbreaks of disease progression (stopping new flair-ups). Moreover, symptomatic treatment of multiple sclerosis are an important part of its control, which in combination with immunomodulators improve the quality of life in patients.

It is important to say that MS has four forms of manifestation, which will be treated timely. The most frequent form is the relapsing-remitting type. According to Dr. Barbosa Rodrigo Thomaz, Neurologist of Hospital Israelita Albert Einstein (HIAE), "in 85% of cases, the disease manifests itself that way. That is, the person experiences episodes of neurological disfunction - a difficulty in view, tingling, loss of motion in the leg, for example. This lasts for days or weeks. After the individual improves; will recover without sequelae. On average, outbreaks recur once a year."

The neurological symptoms observed in MS are variable, the manifestation of a symptom depends on the region of the central nervous system (brain or spinal cord) the got affected. For this reason, there are no typical neurological manifestations that characterize the presence of a new outbreak, but visual disturbances, limb weakness, imbalance, incoordination, changes in sensitivity and urinary disorders are the most frequent complaints. It is also possible that an outbreak is detected by MRI, and when, even without apparent symptoms (because the affected site), the neurologist will identify lesion (s) inflamation (s).

Typically, newly diagnosed patients tend to consider each new sensation as a new outbreak. However, it is important to know that to be considered a new outbreak the appearance of a new symptom, or the sharpening of a pre-existing, must persist for a minimum period of 24 hours.

Fluctuations that occur throughout the day, with periods of worsening neurologic manifestations, although uncomfortable, do not characterize a new outbreak. There are several factors that can cause the worsening of symptoms, such as infections and activities that cause an increase in body temperature - like exercise - very hot environments, fatigue, among others.

High doses of intravenous anti-inflammatories are the standard treatment for cases of outbreaks of Multiple Sclerosis. The most common is called pulse therapy with corticosteroids.

The term pulse therapy means the administration of high doses of medicaments for short periods of time. In Multiple Sclerosis the pulse therapy with steroids is the treatment of exacerbations of symptoms (relapses), which have the aim to decrease the inflammation associated with demyelination process, speeding the recovery from an acute attack.

The most commonly prescribed corticosteroids is called methylprednisolone (Solu-Medrol®), which is administered at a dosage of 500 to 1000mg per day for 3 to 5 days. After intravenous, administration can be followed with oral corticosteroids (prednisone) for 5 days or more by reducing the dosage gradually to the suspension (so called weaning).

The administration of intravenous corticosteroids should be performed in a hospital or outpatient, but is not always required hospitalization, which is a medical judgment based on history and assessment of the severity of the patient. In both cases, the patient should receive medical supervision during and after pulse therapy with corticosteroids - this is critical because side effects may occur.

There are a number of side effects related to corticosteroids. The benefits of the drug must be weighed because of the possible side effects, make sure to discuss with your neurologist. The most common side effects of therapy are:

• emotional lability (quick and causeless change of mood or state of mind);

• insomnia and / or sleep disturbances;

• gastrointestinal disorders;

• palpitation (faster than normal heartbeat);

• metallic taste in mouth;

• increased appetite;

• weight gain;

• hypertension;

• redness of the face;

• swelling of the ankles;

• acne;

• water retention;

• bodily pain;

• psychological and psychiatric symptoms (euphoria, hallucinations, depression and psychosis);

• loss of potassium;

• transient hyperglycemia.

Periodic pulses of intravenous methylprednisolone (on a monthly basis, for example) are used by some neurologists for patients with Progressive Multiple Sclerosis (Primary and Secondary), but increase the risk of side effects and there is no strong evidence that they have a favorable impact on progression of the disease.

Considering all the potential side effects caused by the use of steroids, when a patient with multiple sclerosis needs pulse therapy with methylprednisolone, he or she must follow these precautions:

• as the corticosteroids can stimulate the appetite and increase retention of water, it is advisable to follow a low sodium diet (low salt) and / or rich in potassium, control caloric intake;

• corticosteroids may lower your resistance to infections, causing contamination which is harder to treat. It is important to immediately contact a doctor if you notice any signs of infection such as sore throat, fever, cough or sneezing;

• avoid contact with people with chickenpox or measles, immediately inform your doctor in case of exposure to these diseases. Do not take any vaccine immunization (especially live virus) before consulting your doctor. People with whom you live should not take oral polio vaccine while performing the pulse therapy, since the virus can be transmitted;

• corticosteroids can affect the levels of blood sugar in diabetics;

• although no specific study exists, the excessive use of corticosteroids during pregnancy and / or while breastfeeding may slow the growth of the baby after birth;

• corticosteroids may produce psychological and psychiatric symptoms (euphoria, hallucinations, depression, psychosis and / or mood swings). These disorders can range from relatively mild to very intense, which may change from level to a single individual in the course of treatment. There's no telling if the pulse therapy is likely to cause psychological and psychiatric disorders. If you have a history of mood disorders (depression or bipolar disorder, for example), share this information with your doctor;

• fatigue is typically worse during an outbreak, so it will be necessary lots of rest. Furthermore, it is important to prevent that your corportal temperature increases as it may worsen this condition;

• to recover from an outbreak may take time - weeks and even months. Symptoms of a recent outbreak may disappear completely, but sometimes you can end up with sequels or some difficulties, which tends to worsen over time (accumulation of outbreaks). It is important to consider physical therapy and rehabilitation in these cases.

It is important that in the presence of neurological symptoms for over 24 hours long, either new or worsening of pre-existing symptoms, the patient should immediately cotact the neurologist so the suspected outbreak is confirmed or not. Starting treatment early is crucial to preventing neurological sequelaes.

SOURCES: Healthline

Leandro Teles - Neurologista

BCTRIMS

National MS Society - EUA

MS Trust

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